Big news on the Metlife front and many thanks to Teresa Duncan at Odyssey Management for giving us a heads up for us to research the impact and share. I’m covering how I think it will apply to established practices and we’ll add more information about how it will apply differently to start ups.
As offices that already participate with Metlife know, it’s one company that is typically non-negotiable and has a fee schedule that’s tough to manage. But, it’s always been a fairly black and white in that Met has directly handled their own fee schedule and participation with Met has been by directly contracting through Metlife only. Effective January 1, 2013 MetLife’s PDP+ network has become listed under the Connection Dental, DenteMax and other third party administrators. What does this mean?
If you are currently contracted with Metlife but NOT a third party administrator
When you are directly contracted with an insurance company then the fee schedule tied to that direct contract typically takes precedence over a third party or reciprocal network. This means if you are directly contracted with Metlife your Metlife patients will continue getting paid on the Met fee schedule you are currently under. You will not see a change with your Metlife patients or the fee schedule that you have for those patients. Third party administrator patients do NOT shift over to your Met fee schedule, this agreement only works one direction. Then the question becomes if you could potentially get paid better on Metlife patients through a third party depending on which is paying higher. But if you add a third party contract because the fee schedule is higher with the idea that you’ll get paid more for Met patients then be aware of all the other companies you’ll be adding that also fall under the third party fee schedule. Be sure you understand all sides of the issue before making any impulsive decisions.
If you are currently contracted with a third party (Connection Dental, DenteMax, etc) but NOT Metlife
If you are contracted with a third party but you are NOT contract with Metlife then you need to see how the move in-network would apply to you. As of now (Feb 2013) our latest information is that this change will apply only to the PDP+ Network (not PDP or Tricare). You may get the PDP+ patients to fall under the third party contract but be aware there is no guarantee that they have to pick you up.
You want to know how much Metlife production you have with the PDP+ network because that pool of production will shift over to being in-network and will be paid at the third party rates assuming your office gets picked up by the third party. Across the country we consistently see Metlife as the 2nd or 3rd top production source in most practices so this could have a big impact on many practices, depending on how many of your Met patients are in the PDP+ pool. You can go on the Metlife website to see if a patient is in the PDP+network but you would not be able to pull your PDP+ production numbers from your practice management software at this time because the PDP+ network is new and an office would not have been able to track production tied to it in the past.
If you are currently contracted with BOTH a third party and Metlife
This is more complicated and recommendations are very practice specific. In some areas the third party fee schedule is higher, in some areas the opposite. One office may be contracted with a third party as well as a bunch of other companies directly in which case the third party is only picking up companies that you’re not directly contracted with. The impact of a third party administrator varies for each practice depending on the mix of direct contracts vs. how many companies fall under the third party administrator in that particular practice so there’s no way to make a general recommendation about route is best, it completely depends on how you are contracted and how much production you have tied to the affected insurance companies. It would seem like an attractive option to drop Metlife’s direct contract and let the third party pick up Metlife patients if it’s a higher fee schedule however be aware that your practice may be comprised of a low amount of PDP+ patients (the ones that have the tie to the third party).
A few general notes:
This one is a game changer!